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Comment by TomOfTTB | Hacker News Reader

The problem with his thesis is most rational disagreements in government revolve around things that are either impossible or can only be done by the government. So inefficiency isn’t really the issue.

Take health care as a perfect example. Having studied the issue I personally think it’s impossible to have quality universal health care. Others disagree. But what we can both agree on is that only Government could do it if it is possible.

So the question isn’t inefficiency because both sides concede government is inefficient. But if government is the only power that can do it than inefficiency isn’t the issue. The conflict lies in what can be accomplished not in whether government could do it efficiently.

(People like me would argue the question is whether the private sector could provide better quality health care to more people but as long as the other side believes universal health care is possible the point is moot to them)

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> But what we can both agree on is that only Government could do it if it is possible.

How so? The government could mandate health insurance, and provide a health care option for those who choose not to get it from somewhere else. If enforced, this would make health care (of some sort) universal to everyone.

> So the question isn’t inefficiency because both sides concede government is inefficient

I agree with you that this is a central weakness in John C's argument: Libertarians (like myself) spend a lot of time trying to convince others that the government is inefficient, when the argument can only be resolved by quantifying exactly _how_ inefficient it is, whether the costs override the benefits. This is a much harder proposition to prove, though I suspect that John C is right that the costs almost always are greater than the benefits.

Re : costs almost always are greater than the benefits

Perhaps you can argue this on a case by case basis, but do you think this is still true if you have to take or leave all service at once?

As evidence that the costs are worth the benefits I submit the fact that you (perhaps not you in particular but any citizen of a country who makes this claim) haven't renounced your citizenship for that of another, better cost-benefit ratio, country.

Incidentally, I think that if many government functions were privatized you would be paying a (much) higher rate than you are now since you've already shown the willingness to pay the current rate. That combined with the fact that there rarely if ever is competition in large scale services like those the government provides. As evidence, take a look at any large scale private contractor industry like construction or defense/aerospace.

There's something offensive to me about the idea of renouncing citizenship to protect your own property. It's like abandoning your house and moving away to avoid burglaries. I have a right to my own labor and property. The thieves and robbers should be the ones to leave.

Does that mean you never have a similar experience doing business with private companies? I think booking a hotel room or flight can be a comparable experience if it goes poorly.

> As evidence that the costs are worth the benefits I submit the fact that you haven't renounced your citizenship...

That's actually a good argument. Though of course I'd incur huge expenses moving to another country than the one I was born in (new language, no contacts, maybe fewer legal rights, etc) so it only works up to a degree.

> I think that if many government functions were privatized you would be paying a (much) higher rate than you are now since you've already shown the willingness to pay the current rate.

That makes no sense... Are you saying I wouldn't buy an umbrella for $2.99 at Walmart because I bought an umbrella for $12.99 at a mom-and-pop store before Walmart came to town?

The huge expenses you incur for moving are part of what the private companies would extract from you. While the company may be able to "efficiently" provide you a service for for 1/10th the equivalent government price, they will charge you something like 95% of the "total cost" of you switching, whatever that may be.

The issue is that you won't have 10 or 20 providers for roads, water, electricity, landlines. Anything where infrastructure costs are high or where its nearly impossible for two providers to have identical, commoditized services as with roads will not be competitive.

For things like getting a passport, driver's license, etc you will have some competition, but there are plenty of private companies that provide crappy service as well. How many people who buy cheaper merchandise later think "what a piece of crap"?

Incidentally, I think that if many government functions were privatized you would be paying a (much) higher rate than you are now since you've already shown the willingness to pay the current rate.

If you don't pay your taxes, you'll get put in a cage or shot. That's not a "willing" payment.

A country and its government are not the same thing. The cost-benefit balance can be made positive by benefits that are independent of government, such as cultural attitudes or proximity to specific private institutions.

But what we can both agree on is that only Government could do it if it is possible.

Hell no. A combination of private charity and vigorous markets have provided quality universal food and entertainment. Government is presently attempting quality universal housing and education -- and its failing miserably on the "quality" point, and ain't doing that great on the "universal".

If quality universal health care comes from anywhere, it will be from Silicon Valley & Red Cross. The most government will ever do is mandate it, try to implement it, fail, and claim it's doing its best and just needs a little more money.

A combination of private charity and vigorous markets have provided quality universal food and entertainment.

I can't think of a single country where there is no government food assistance and no one starving to death. Where are you thinking of?

I was thinking of the US. I'm aware that the government helps on the food front, but I don't think that's why food is abundantly available and cheap. Folks who have nothing go to soup kitchens before they apply for EBT, and they eat pretty well.

Some might disagree that EBT is not a major contributor, though. Point retracted. I guess I just have 'entertainment'.

I think you're just misinformed about this issue.

http://feedingamerica.org/faces-of-hunger/hunger-in-america-...

About universal health care, go to France sometimes.

people below the poverty line in the US consume extremely low quality food. And most wouldn't even have that if it weren't for government food stamps.

> "people below the poverty line in the US consume extremely low quality food."

Is that because they can't afford medium-quality food, or because they're choosing to buy substandard food anyway?

I've gone shopping with people way below the poverty line; in every instance, they spent as much as I did for a similar time period, at the same quality of store, and yet came out with far crappier food. I don't know if my experience is typical, but I find it hard to believe, given the prices on various types of healthy and unhealthy foods, that "eating low quality food" is a result of lack of money.

> Take health care as a perfect example. Having studied the issue I personally think it’s impossible to have quality universal health care.

Just out of curiousity: Do you mean impossible in the US, or in general?

In general. At least in the terms most people define Universal Healthcare. The problem with Universal Healthcare is you're taking a limited resource (doctors, medicines, equipment, etc...) and trying to treat it like an unlimited resource. I mean, In the U.S. there isn't a big problem with doctors being unemployed or an overflow of surplus meds right now yet universal healthcare is unquestionably going to add a lot of new customers to the existing health system.

If that's the case in the U.S. imagine countries like China or poor African countries with even fewer resources.

I'm not happy with that reality from a humanitarian perspective but I don't see how it isn't the case. Being a doctor is hard and there are only so many raw materials out there so I don't see a way around it.

(But the important point here is that it is debatable and that's where the problem comes in)

> "The problem with Universal Healthcare is you're taking a limited resource (doctors, medicines, equipment, etc...) and trying to treat it like an unlimited resource"

No, that is a lie. What Universal Healthcare is about is about a better distribution mechanism.

The market is a mechanism for efficiently distributing a limited resource based on people's ability to pay.

Universal healthcare aims to distribute a limited resource based on need not ability to pay. Proponents like this because it is fairer and doesn't leave people suffering. Capiche?

I'm sorry but your argument boils down to you not wanting to see the other side of the debate.

What you're saying doesn't change the fact that the resource is limited. The question is can the limited resource be stretched to accommodated everyone and if so can government create a more efficient distribution method to harness that resource. Because if either of those things aren't true than your "need-based" distribution is going to leave as many if not more people without treatment (it will just be richer people)

That's the debate: Is it possible to give high quality health care to everyone?

You stating that there are enough resources as a certainty is just arrogance on your part.

I don't see anywhere in his comment where he claims that there are enough resources to give high quality health care to everyone. He states that the distribution should shift from a "who can pay" based mechanism to a "who needs it the most" based mechanism.

Yes, as you mentioned, you would certainly see more wealthier individuals that would be denied care. You would also see more poor people getting care they desperately need.

>That's the debate: Is it possible to give high quality health care to everyone?

I don't think this is really the debate. I think the debate is whether or not health care should be portioned out based on how much money someone is willing to/able to spend or based on how badly somebody needs the treatment. Personally, I think that's the only moral way it can be done.

Universal healthcare aims to distribute a limited resource based on need not ability to pay. Proponents like this because it is fairer and doesn't leave people suffering.

And opponents dislike this because it's impossible. If such a magical distribution method existed then we should obviously be using it for everything, not just healthcare, and that's called socialism.

Works pretty darn well here in the UK. Impossible my arse.

I'm not saying the UK's system is impossible. I'm saying it is staggeringly, almost criminally inefficient. I'm also not saying the current US system is better; we have our own set of regulations that have made our healthcare system as inefficient as any in the world.

Actually, my main problem with the UK system would be that they're too focused on efficiency at the expense of quality. That is, anywhere other than in their provisioning of IT systems, where they're focused on neither.

I consider efficiency to be secondary to the saving of human lives or the general improvement of people's living conditions by curing them of curable ailments.

Coming from a country with a "socialist" healthcare I was very surprised by how much money I'm paying in the US for health insurance, it's more than what I was paying in taxes and when I actually want to use my health insurance I still have to pay considerable additional money to actually get the serivice. And it's also extremely inefficient, there is no reason to measure my weight, temperature, blood pressure and breathing if what I have is clearly tendonitis.

Long story short: I think your health care market got you the worst possible solution to health care in the world.

But who determines need? There's the rub. I would much rather write a check to a charity like the Red Cross than the massive bureaucracy that is DHHS, because (a) there is just a lot less overhead and because (b) the Red Cross' definition of "need" is a lot less likely to shift in the political winds. For example, in a couple of years DHHS may be back to persecuting stem cell researchers.

Red Cross is a high overhead orginisation:

An American Red Cross statement was issued saying that 91 cents of every dollar donated specifically for the Hurricane Katrina disaster will go directly to disaster relief. This overhead of only <B>9%</B> is quite low for such a large organization. http://en.wikipedia.org/wiki/American_Red_Cross

Social Security is impressive because "the dministrative costs of the U.S. Social Security system are very low--<B>less than one percent of revenues.</B>" She claims this compares favorably with the overhead costs of the partly privatized Chilean system, which she says are "in the neighborhood of 15 percent of revenues." http://www.highbeam.com/doc/1G1-19085869.html

1. DHHS != Social Security 2. The core point is choice. I prefer donating to a neighborhood charity that I can confirm is spending money responsibly. If you believe the government generally provides healthcare with lower overhead and more efficiency than a private nonprofit, one might politely point out that same government has spent several hundreds of billions has been spent blowing people up in Iraq. I don't think even the Red Cross spends its 9% on that...

Well, in most cases where there is socialized medicine, doctors decide on need, and groups of doctors decide on standards.

politicians play no role.

I never understand this generality, when the US stands as the only 'developed' nation without universal health care?

In Canada we have universal health care, and it works reasonably well. Some would argue waiting lines and all that, I've never experienced them to be that bad, I live in a large urban center (Vancouver) and have found the services to be exemplary.

Again this is getting into the actual debate which I think is more complicated than people make it out to be but I think it is possible to provide baseline care and I think the U.S. should do that. Where you see a constraint on resources is in specialty areas and you hear stories all the time of people with specialized ailments coming to the U.S. and spending money for treatment.

> and you hear stories all the time of people with specialized ailments coming to the U.S. and spending money for treatment

I'd rather hear stories like that then stories about people denied treatment because they got denied by some corporate bean counter.

And your stories aren't indicative of any failing of the Canadian system. Let's not forget the American's that rely on Canada for their health needs.

There's a flawed assumption in your statement that Canadians aren't denied access to coverage due to government bean counters.

I have a relative who is an Oncology nurse in a major US city. She sees a lot of patients from Canada who come to her hospital because they can't get the treatments they need in Canada. Of course, it's only the wealthy ones, because they're the only ones who can afford it.

Similar problems exist with the US government healthcare (through the VA). My father was denied a lifesaving transplant because he didn't meet the government board's criteria for a transplant. Mayo Clinic came through with the transplant and saved his life.

> There's a flawed assumption in your statement that Canadians aren't denied access to coverage due to government bean counters.

On a much lower scale then in the US. I see first hand the realities of the differences between the two systems. In Canada, their is much less worry about health care than in the US. Their are still issues, but not the same fundamental ones that the US has.

This also ignores the fact that Canadian patients often go to the US for reasons other than the one you describe. Often times, they go to a hospital known for being the best in certain types of care. Other times, it's also a timing issue: they want it resolve sooner than what Canada will do for them.

Finally, the same problem exists on the private side as well. Health insurance companies deny lifesaving operations all the time.

Edit: Another problem with your argument is the assumption that Canada doesn't have private insurance on top of public. It does. It sits on top of the public insurance. And while it's great your father got help from a non-profit, I wonder how much help he would have gotten from a non-socialised health care plan?

Other times, it's also a timing issue: they want it resolve sooner than what Canada will do for them.

Isn't that a huge problem though? For cancer and other progressive illnesses, each day's delay can mean the difference between surviving or not.

It depends on the illness and the severity. My wife's parents and family have never been turned away or made to wait for urgent things, including cancer. The decisions regarding this are made by the doctors. They can expedite things if they think it merits expediting. However, just because something isn't as serious doesn't mean someone wants to live it with, so they can pay extra to get it resolved quicker.

All I know is a friend of the family under only Canadian health care was covered for a quadruple bypass surgery something I am told in the US would effectively bankrupt any normal non-insured citizen, and has made a full recovery to the point that he can now go Skiing with us again.

There may be some short comings to our system, and inefficiencies but I will say I am pretty damn happy that I live in a country that provides that level of coverage to any citizen.

I guess it comes down to what you mean by "quality", but Canada has pretty good health care provided by the government (we call it "universal" here, but I suppose we should precise our definitions).

For the record it isn't like the Canadian health care system is all smooth sailing: http://www.economist.com/node/16542808?story_id=16542808&...

I certainly think the U.S. should try to learn from some of the things Canada has done but at the same time Canadians need to acknowledge they have some kinks to work out as well.

Canadians are very critical of their health system, but this discussion takes place in the context of the existing Canadian system. It's only on comparison to the American system that the Canadian one starts to look good, or even excellent.

Canadian health care has problems. Nothing is perfect. But don't confuse having problems with not being vastly superior to the US system.

My wife has her issues with the HCS here, but she's scared to death of the US system should we ever move there (being American myself). Their is a reason the guy behind Canada's health care system was made a national hero.

I've proposed a solution elsewhere but I'll quote it here:

We already have a pretty good K-12 public education system. At least it's pretty good for its original purpose which is to make better workers. I say we overhaul the K-12 system so that by the time each person graduates they'll have the equivalent of 3-5 years of medical school. Then, in addition to college + traditional medschool (or just votech), give people the option of attending a publicly funded quasi-votech-medschool, the graduates of which will be licensed to practice medicine (and these people will have about 7-9 years of training at that point).

So, we would have simultaneously increased the number of doctors and nurses, decreased the need for them (since medical knowledge will be more or less ubiquitous), created some parity in knowledge between health care providers and consumers (the disparity is one of the big reasons a free market can't work). Most importantly, since medical knowledge/skill will be so pervasive we would see a lot more innovation and entrepreneurial activity in that space. Instead of people working on the next Facebook in their garage/dorm room we might have them working on new kinds of equipment, treatment, or even medicine (like that doctor that built a dialysis machine in his garage: http://www.dailymail.co.uk/health/article-1180628/D-I-Y-dial...). Or perhaps more stuff like this: http://www.wakemate.com/

Simply make everyone a doctor of sorts.

That's a little ambitious. 3 years of medical school before they graduate high school? How about we catch up to the rest of the world first. The US K-12 education system is actually not that good. http://www.ecs.org/html/offsite.asp?document=http://nces.ed....

As an American with a chronic condition living in Sweden I can agree with you. However the Swedish system does a lot to eliminate and streamline the system. Calling to get an appointment gets you on the phone with a nurse to triage you, so urgent things are seen urgently and non-urgent things get scheduled in. I know doctors and go to doctors in Sweden and they see drug company reps significantly less than American doctors do. They aren't allowed to meet with drug reps like happens in America. I went to a hematology/oncology clinic in the US and there was always drug reps coming and going, if they had cut that down they'd be able to see more patients, and keep their appointment times with their patients. However these doctors it turned out whored themselves out not so much for the free meals and such, but to collect as many free samples as they could so their poor patients could be given at least a partial supply of drugs they would otherwise not get.

For my particular condition a subcutaneous treatment was developed in Scandinavia and the UK. It costs half as much to treat a patient and requires no care from a nurse to administer the alternative IV. I can give myself my drugs on my own time instead of taking time off work to go into a clinic. The drug is finally making its way over the pond now, but uptake is slow. Not every person with my condition can go on the subcutaneous, but back of the envelope math says at the very least $100 million a year would be saved if all patients who could go on went on it. In addition 150,000 nurse hours would be freed up as well each year.

Let's not forget the personal savings of time being on the phone with the insurance company. In the year before I moved to Sweden I lost roughly a week of work to being on the phone with the insurance company cause things weren't billed right or they just decided that I didn't need my IV anymore or getting them to pay for things they pre-authorized, but decided to deny when the bill showed up. I have spent absolutely no time discussing those sort of things in the last 3.5 years I've lived in Sweden. That's time I spend earning money and paying taxes, which seems to be win-win.

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